Survivors of Suicides: Struggles with Complicated Grief and Approaches to Treatment

Anna H.
Sallie Foley
SW617- Death, Loss and Grief
Intellectual property of the writer. Do not use without express permission.

In his book on addressing grief from a clinical perspective, Grief Counseling and Grief Therapy, Worden (2009) reserves much of a particular chapter specifically to address the issues that arise when faced with a death due to suicide. It is, he notes, a particular type of grief which causes much trouble beyond the normal feelings of pain and loss at the death of a loved one: “Nearly 750,000 people a year are left to grieve the completed suicide of a family member or loved one, and they are left not only with a sense of loss, but with a legacy of shame, fear, rejection, anger and guilt,” (179). Out of all the different experiences throughout the western world, few evoke as complicated and visceral a reaction as surviving a loved one who has died due to suicide. Suicide has been criminalized in countries and been deemed a sin by many cultures; many people frequently continue to see it as the ultimate act of selfishness. It is a type of loss where people don’t send condolence cards, one that is often left unacknowledged, and for which there are few, if any, good explanations. Suicide causes so much disruption among families and communities beyond the normal scope of grief for the death of a loved one that many surviving friends and family struggle for years with loss that stigmatization, coupled with shame, rage, confusion and guilt makes more complicated than any other type of death we encounter. There are, however, many therapeutic means through which people can alleviate these complex and burdensome layers of grief, so that in time they may uncomplicated their grief enough to incorporate it into their love and memories of the person they have lost. This paper will discuss in greater depth the various types of struggles surviving loved ones face when they shoulder the complicated grief of a completed suicide, and several modes of therapy which have been found particularly helpful in mediating their pain.
Grief reactions to the death of a friend, loved one, or family member always include sadness and periods of pain in missing the person whose life has ended. When a the loss is due to suicide, however, these normal feelings can become terribly enmeshed with a myriad of other, often more destructive feelings caused by stigma associated with this particular type of death. “Suicide survivor” is term which has come into clinical parlance to describe anyone who experiences these significant, painful consequences for a suicide within their social network, and there is a recognition that this term is applicable to a significant percentage of the population—perhaps as many as 7% of people in the United States (Jordan, 2009). While not everyone exposed to suicide feels its impact in the same way, the grief experienced by survivors of suicide is most commonly characterized by the shame and guilt they carry with regards to their connection’s death, compounded by other tumultuous emotions such as anger, hurt, betrayal, confusion, and— frequently— shock at the unprepared-for loss. There are thoughts that for many, these complications for survivors of suicide, like those who survive the loss of a loved one to an accident, are suffering in large part due to the sudden, unexpected nature of the death, for in such losses there is no time to say goodbye, or prepare one’s self for the absence of the deceased (Lindqvist, Johansson, and Karlsson, 2008). However, Jordan observes that there are no “clear operational definitions” for a suicide survivor, along with a notable lack of longitudinal studies with regards to their integration of the loss, further indicating that, at least within Western culture, there remains a significant taboo when to dealing with suicide and all that it touches, even when it comes to helping treat those who suffer in its aftermath (Jordan, 2009).
Feigelman, Gorman and Jordan (2009) discuss in great detail both the ways in which stigma in response to suicide has developed in Western culture and the damaging effects it can have on the dead person’s survivors. In Europe, from as early as the Middle Ages the punishment for suicide from the Church and the State extended beyond the deceased to their family: property could be confiscated and held by governing agents, and all immediate relatives could be excommunicated from the Church (Feigelman, Gorman and Jordan, 2008). It is the continuation of this stigmatization, coupled with guilt, which appears to be the primary cause for complicating the grieving process for survivors of suicide up to the present day. In a survey conducted with grief support groups, Feigelman, Gorman and Jordan observed that, when comparing the effects of stigmatization responses in a group of 462 parents who had lost children to suicide with 54 whose children had died to traumatic death and 24 from natural causes, those parents who encountered stigmatizing responses from their peer, support and family groups had greater difficulties with their grief, including the development of depression and suicidal ideation on the part of the survivor, (Feigelman, Gorman and Jordan, 2009).
Distorted communicative perceptions based upon stigmatization within family and social systems in reaction to the suicide can have a significant impact on the ways in which the survivors cope. Families can experience, or themselves develop feelings of blame (or being blamed) for the death, feel the need to keep the nature of the death secrete from extended family or the larger community, and undergo a sense of social ostracism (Jordan, 2008). Even for those who do not encounter any outright negativity regarding their loss, the experience of ambiguity and lack of social protocol for how to be supportive of a family grieving for this sort of loss can lead to exacerbated feelings isolation, shame, and condemnation (Jordan, 2008; Worden, 2009). Worden describes a client who came into his office and lamented that “‘no one will talk with [me]… they act as if it never happened,’” (Worden, 2009). This is not to say that there is no social support for survivors of suicide, nor that all social interactions produce feelings of shame or stigma; there is evidence to suggest that near to half of the survivors of suicide may experience a strengthened feeling of closeness to their remaining living family members and friends or support structure (Feigelman, Gorman and Jordan, 2009). For the other half, however, it does underscore the complicated reactions both felt by the survivors for themselves and as members of the community in which they live. What may be of most import when considering the negative effects of stigma is the expectation— prevalent throughout the centuries, despite the growing recognition in our present time that suicide is almost always predicated on mental disorders and psychological illness— that there will be little support for the survivors, and that they are somehow to blame for their loss (Feigelman, Gorman and Jordan, 2009).
The other, perhaps most pronounced experience for survivors of suicide is the often overwhelming sense of guilt they feel: for not anticipating the actions which caused their loved one’s death, for not recognizing their pain, for not being able to somehow save him or her, and in turn, save themselves the pain they and others sharing their experience now feel. As with stigma, Pridmore and McArthur note that feelings of guilt have been associated with suicidal loss since antiquity in the West; going back as far as ancient Greece they see maladaptive feelings such as guilt, shame, anger, and sorrow (Pridmore and McArthur, 2009). Worden discusses that while guilt is frequently a feature of normal grief responses, the amount of guilt felt by survivors of suicide is inordinate and often overpowering (Worden, 2009). People who feel this amount of guilt can end up feeling themselves deserving of punishment, which can be very damaging to the survivor’s psyche and in turn can have physical consequences (Worden, 2009).
This sense of pervasive guilt may be especially the case for children and adolescent offspring of parents who have died from suicide: apart from the negative indications parental suicide has for child mental health outcomes in the future, the disruption of family functioning both before and after a parental death from suicide can have a significant impact on the psychosocial functioning of offspring (Kuramoto, Brent, and Wilcox , 2009). Worden discusses the ways in which reality testing when working with youth is particularly important, that families and clinicians be alerted to self-blaming and guilty feelings in children, as there is a correlation between being affected by suicide as a survivor and the survivor experiencing suicidal ideation in him or herself (Worden, 2009). Higher levels of shame, anxiety and anger have all been found in adolescent children whose parents died by suicide than in those whose parents were killed or died in other, less traumatic ways, and there is an increased risk for behavioral problems, well as possible decrease in overall functioning within the bereaved family unit (Cerel, Fristad, Weller and Weller (1999) in Kuramoto, Brent, and Wilcox , 2009). Jordan notes that many people incorporate their feelings of guilt and self-blaming into an ongoing analysis after their loved one’s suicide to determine if they were somehow the cause of it; unfortunately, these feelings, and the need to assuage them, can cloud the survivor’s recognition that their loved one, like up to 90% of suicide completers, had severe mental health disturbances, and these—not their actions or inactions—were what led the loved one to take their own life (Jordan, 2008).
All grief incorporates these elements or guilt and a wish to blame, and while the expectation of stigmatization appears to be particular to survivors of suicides, the social isolation felt by those who are grieving can cause additional pain beyond their initial loss; in the complex grief of survivors of suicide, there is another piece, comprised of anger and feelings of abandonment, which prolongs and further complicates the survivor’s ability to integrate their loss back into the tasks of living. Worden discusses the intensity of angry feelings survivors may experience when they perceive the death as a rejection; children and spouses may feel betrayed or as though their loved one’s death was a direct means of leaving them, and their grief may take on qualities of resentment or even rage (Worden, 2009; Kuramoto, Brent, and Wilcox , 2009). These mixes of emotions often feed into their guilt, and can have an impact on self esteem, that they feel as though their worth as the survivor is less because they were the ones who were left. There may also be questions in the survivor’s mind as to whether their deceased loved one was driven to death, which can be compounded by feeling of anger and hurt that they felt the need to kill themselves, or were not ‘strong enough’ to continue living (Jordan, 2008). Guilt and unworthiness at surviving often war with rage and immense pain at being left alone. Particularly in the case of teenage suicide, where there may be little sign of severe emotional distress disclosed before the act of suicide, surviving parents struggle with the unexpected nature of the death, their anger at being deceived by their children, their overwhelming pain at the loss of a child, and their guilt as seemingly failed parents (Lindqvist, Johansson, and Karlsson, 2008). Without intervention, such complicated grief, especially if coupled with post-traumatic stress if the survivor was a person who discovered their loved one’s death or body, can mix to cause grief so complicated that it overwhelms a person’s ability to work through their loss on their own such that they can continue living (Jordan, 2008).
In order to help intervene in complicated grief for survivors of suicide so that they are not wholly overrun with their feelings and cease to experience life themselves, it is of primary importance that the clinician acknowledge the death of their loved one and the entire spectrum of grief they feel because of that loss, to aid in overcoming the first hurdle of dealing with an unspeakable loss (Worden, 2009). The stigma of such a socially unacceptable behavior must be undermined in the eyes of the client, both so that the therapist may form an alliance with them and that they may feel that here is a safe place to begin coming to terms with all their feelings regarding their survivorship without being judged for any of them. Given that barriers to grief experience stemming from negative experiences regarding their loss can be linked to depression and suicidal thinking on the part of the survivor, it is paramount that a therapist acknowledge the reality of the loss along with the client, and bridge the loss of community they may have experienced (Feigelman, Gorman, and Jordan, 2009; Worden 2009). In surmounting the feelings of social and community isolation, it may be necessary for the clinician and client to take stock of what relationships are healthy and supportive to that client, and which may be more painful than they are worth currently (Feigelman, Gorman, and Jordan, 2009). This may even entail supporting the survivor in instructing their support system how to better work for them, which in turn will help destigmatize the association with the type of loss they are experiencing. Establishing this groundwork of support and belief for the client’s feeling, whatever they may be, is important in all cases, but all the more so when they are the survivor of a socially unacceptable loss.
While accepting the losses and the tumult of emotions the survivor has faced, however, it is important to keep in mind that the therapist needs to reality test a client’s feelings of guilt and blame, gently challenging or correcting distortions as they come up in conversation. Such gentle questioning can be highly appropriate for a client who feels excessive guilt, shame, or abandonment, as these feelings can stand in the way of Worden’s second task, processing the pain of grief. He gives the example, for instance, that it is acceptable for survivors to feel some level of relief that a person who had been experiencing such emotional anguish might no longer be in pain, even as they also feel anger at that person for leaving: such a jumble of emotions not only needs to normalized, but examined from an outside perspective, in order for a client to come to terms with all that they feel in association with their loved one’s actions (Worden, 2009). Similarly, while relieving the guilt many people feel for just having emotions which might be deemed somehow inappropriate, it is also necessary to give them the permission to feel as they do. These normalizing and giving permission tactics can be utilized either in one-on-one or group grief work settings with success, as individual attention and contact with other survivors are both beneficial in acknowledging the unique horror and relieving the isolation associated with suicide (Jordan, 2008). The best supports for survivors may come from other family members and close social connections, and it may be useful to incorporate them into a therapeutic situation, to act as witnesses and, in doing so, assuage some of the guilt and stigma of grief of this nature (Feigelman, Gorman, and Jordan, 2009).
Stepakoff (2009) suggests that, since suicide explicitly is a destructive act, a treatment of particular use for survivors of suicide involves active and willful countering of destruction, in the form of finding meaning and solace in creativity. To this end, she recognizes poetry therapy, the “utilization of poetry and related forms of literature and creative writing in order to improve psychological functioning” as a technique which is of great help to some survivors of suicide (Stepakoff, 2009). Lindqvist, Johansson, and Karlsson (2008) suggest that one of the hardest things to cope with is a survivor’s attempt to see a meaning in the actions their loved one has taken, and it can play a vital role in the ways in which survivors struggle with or accept their loss. Poetry therapy, therefore, is a means by which survivors can break their silence and express their struggles regarding the meaning of the suicide in an externalizing manner (Stepakoff, 2009). She outlines what she sees as the four primary tasks of for using poetry in working with survivors of suicide as:
“(a) to describe, in a fresh, creative manner, common aspects of the grieving process after a suicide, thereby helping participants feel less isolated; (b) to model exceptionally honest and brave self-expression, thereby freeing participants to express themselves more frankly and fully; (c) to give external form to internal, difficult-to-articulate emotions and perceptions, thereby helping participants contain their psychological pain; and (d) to serve as objects of aesthetic beauty, thereby instilling in participants renewed feelings of vitality and hope.”
(Stepakoff, 2009).
The approach is in keeping with Worden’s thoughts on helping survivors make meaning of their experiences of pain and grief by participating in the search for an answer for why this terrible even occurred, as well as work through task three, adjusting to a world without the deceased (Worden, 2009).
There are two forms of poetry therapy—receptive, which relies on the use of preexisting poetry, and expressive methods, which invites a survivor to use their own words, in poetry, or other creative writing form—either of which can be used on one’s own, or and especially to start out with, as facilitated by a therapist. Stepakoff outlines the use of receptive poetry as following one of two general methods: the survivor may pick a poem themselves in which they can find meaning and an echo of their feelings about the loss, and can read it aloud or to themselves; alternatively, the therapist can guide the survivor through the process where they facilitate the interaction and chose a poem which seems most appropriate. The former is more often utilized in the context of individual work, while the latter tends to be more in grief group settings, but either way constitutes classic poetry therapy, wherein the client’s task is to discern what they relate to in the body of work, and use it as a catalyst to discuss how they are experiencing their loss (Stepakoff, 2009). The expressive form of poetry therapy utilizes the client’s own words and thoughts to achieve what Worden discusses as the process of grieving; it includes the survivor’s writing down and often reading aloud the thoughts and feelings he or she experiences throughout the therapy, and at specific point in time, as they feel certain things. The theory behind this work is rooted in the idea of catharsis— that it is necessary to come to some resolution of powerful and often hurtful emotions through a purification or purging of the thoughts or feelings—and the practice of externalizing feelings, such as what is used in narrative therapy work, to separate out how a survivor feels from who that survivor is (Stepakoff, 2009). In doing so, the goal is to build in the client the ability to pick up, examine, and feel for a portion of time the overwhelming set of emotions he or she has been fraught with, without being overwhelmed by the constant presence of those aspects of grief within themselves.
It is not the resolution of the grief that is sought, but rather the rebuilding of the survivor’s life with their grief integrated into their future which therapists attempt to achieve when working with such clients (Jordan, 2008). Incorporating poetry therapy and other externalizing models into a framework where the therapist is present and accepting of the pain and grief the survivor brings into the room is a key to working with this population, and in doing so, we as therapists offer a means of easing the sorrow enough that a survivor can, in time, begin to remember their loved one while moving forward with their life.  
Bibliography:
Feigelman, William, Bernard S. Gorman, and John R. Jordan, (2009). “Stigmatization and suicide bereavement.” Death Studies, 33 (7) 591-608.
Guglielmi, Maggie Colleen, (2009). “The impact of stigma on the grief process of suicide survivors.” The Sciences and Engineering, 69(8-B) 5027.
Jordan, John R. (2008). “Bereavement after Suicide.” Psychiatric Annals 38(10) 679-685
Kuramoto, S. Janet, David A. Brent, and Holly C. Wilcox (2009). “The Impact of Parental Suicide on Child and Adolescent Offspring.” Suicide and Life-Threatening Behavior 39(2) 137-151.
Lindqvist, P., L. Johansson, and U. Karlsson, (2008). “In the aftermath of teenage suicide: A qualitative study of the psychosocial consequences for the surviving family members.” BMC PSYCHIATRY, 8:26.
Pridmore, Saxby and Milford McArthur, (2009). “Suicide and Western culture.” Australasian Psychiatry 17(1) 42-50.
Stepakoff, S., (2009). “From destruction to creation, from silence to speech: Poetry therapy principles and practices for working with suicide grief.” ARTS IN PSYCHOTHERAPY 36 (2): 105-113.
Worden, J. William, (2009). Grief Counseling and Grief Therapy. New York: Springer Publishing Company, 4th ed.

Biases and Dilemmas

Anna H
For Laura Nitzberg, Couples Therapy


Upon first consideration, I like to think that I don’t have much in the way of biases for practicing with couples in therapy. I consider myself an ally of folks within the BLGT communities, and therefore believe whole-heartedly that loving relationships between two people are good, no matter what their gender expression or orientations. In a related area of consideration, I consider myself a sex-positive person, and I include within that designation the feeling that, as long as the people within the relationship as they define it are practicing safe, sane, consensual and risk-aware kink—regardless of what their particular kink might be—then they are free to do what makes themselves and each other happy. There are boundaries to this acceptance, of course: all relationships must be consensual, and no partner should ever feel abused or taken advantage of within the context of their relationship, be that in an emotional, physical, sexual, economic, or psychological realm.
These being my base line for acceptance, I realize that I need to consider how I personally feel about relationship styles and communication to better recognize where my biases lie. I do not consider infidelity to be acceptable behavior unless it is within explicitly open and recognized parameters; that is to say, I think the idea of cheating, as opposed to open relationships or polyamory, is wrong. The deception and lying violates the trust and affection necessary for a healthy relationship, and I would probably have a hard time counseling a client who came to me having been unfaithful to his or her partner. I know that people can get over such hurts in their relationships, but personally I would have trouble remaining objective and neutral with a couple where one of the partners had betrayed their relationship with the other in such a way.
Interestingly, while I do consider myself at the very least non-damning of those sexual practices that run counter to my own, I do not agree with promiscuity, both for moral and health reasons. This gives me pause when I consider the separate, but related idea, of swinging, where married couples include other married couples in their sexuality. I feel somewhat conflicted regarding this, because I wish to be at least permissive of others’ sexuality, as it is really no business of mine what they do as long as they are being good to each other. In our culture, and to my way of thinking, however, it feels that marriage takes a couple into a different set of relational boundaries which swinging with other married couples seems to belie. Again, my concern is rooted in abuse and harm, because I have my doubts as to whether couples can truly remain happy and committed to each other, while having sex with other people, given that sharing sexuality is such a fundamental part of what it means to be bonded in romantic relationship with someone else. When a relationship becomes defined by marriage, it feels to me that people are saying they wish to only be with this one person for as long as they both may, whatever that ends up meaning. While polyamorous relationships may accept multiple partners on equal footing or a primary partner and other lovers, the boundaries of the relationships are necessarily set up to allow this, and therefore all parties involved are in agreement as to what that means. This expectation does not exist within the parameters of marriage, and therefore I struggle to accept that people married to one another would want to involve themselves with others, but not consider it infidelity. Other areas where I think I might struggle include circumstances where there is a significant age, socioeconomic, or other power disparity between the two halves of the couple, because I might be skeptical of the potential for abuse in some form.

Personal Reflections on Grief and Loss

Anna H
9/15/09

In considering how I have personally come in contact with death and loss, or experienced grief, I must first acknowledge that I do not feel as though I have had much first-hand knowledge of what it is like to lose someone. I have been blessed to have not lost anyone immediately close to me, neither friend nor nuclear family member. That being said, however, it occurs to me that there are a number of different categories of loss which I tend not to consider to be “as important” somehow when applied to myself (though they are significant in the lives of others). When I allow myself to broaden my approach to loss- as I would with a client, though perhaps reticently for myself- I come to realize that there may be much for me to say on the topic which I can speak to personally.
My experiences with personal grief stem more from an awareness of people and opportunities I have not had. Some of my greatest losses are more concerned with the sense of lacking and wanting, rather than the traditional experiences of severed attachments due to death. I am the daughter of divorced parents, who separated when I was 4 years old; therefore, I have not had the experience of growing up in an intact family system, with the support and ready attention of both biological parents. While the divorce in and of itself might qualify as a major loss, in my mind the grief comes not so much from their separation as such, but from the losses that occur as a result of not having them together. I do not remember what it was to have my parents love one another, to model for me how a good working relationship functions, or for us to work as a happy family. These losses of what I could- perhaps feel I should- have had in my growing up are much more what I feel, as I was not old enough to know what things might have been like before my parents became unhappy with each other. Loneliness, and the awareness of missing good family relationships, has therefore been the most pervasive cause of grief in my life.
Beyond my parents, I have grown up with very few family ties: my parents each were isolated themselves from their extended and nuclear families, and, though for different reasons, the end result was that as their daughter, I know very little in the way of familial support or interaction. My mom’s mother died of breast cancer when I was two and my mother still grieves for her, but I do not know what it is like to feel that pain immediately, because I didn’t get the chance to know her; it is for that that I grieve. My father’s parents both lived in Florida and were very much out of regular contact with my Dad due to his strained relationship with them after they kicked him out of the house at age 18 for getting his first wife pregnant; they both died by the time I entered high school. My mother’s father, who died only this past April, was my last grandparent, but due to the falling out she as the result of much hurt and anger over my grandparent’s divorce and my grandfather’s marriage to the woman with whom he had an affair before that, I too lost the chance to develop a meaningful relationship with him. As much as family means to me in theory, my personal experiences with the ways in which families interact has been extremely curtailed by the actions of my parents, beginning long before I was even born. While I don’t often think of these things as losses per say- they are so far removed from my experiences that I again don’t know to miss them most of the time- when I allow myself to realize the extent of my family connections, I am aware that my ties with family beyond my mother, father and stepmother are only tenuous at best, and due to the nature of relationships damaged before I had a chance to experience them, I inherited the disconnection and isolation of my parents’ choices.
I can remember growing up in some ways very much alone, as both an only child, and the daughter of a single, working mother who out of necessity had to leave me at home, or with care-givers for extended periods of time from the age of 6 until I moved to college. That isolation seemed to follow me into my middle and high school experiences, and in reflecting back on my experiences as an adolescent, I am cognizant of a significant amount of time spent on my own, at home by myself. Because I had very little in the way of extended family connection, I have long been aware that my friends are in many ways my family of my own choosing, and as such the separation and drifting apart that occurs when life stages and physical closeness wane have been acutely and painfully felt on my part. This is my greatest source of fear for future loss, which in and of itself may play a part in my understanding of what it means to experience grief: after the initial pain of a loss has begun to subside, there still remains the fear that another, equally hurtful loss will follow the next time I engage in a close relationship or friendship, and either through loosing again and again, or else by never having the ability to find someone else, I will remain alone.

Grandfather's Legacy

Things I learned from from/about my grandfather, briefly.

There once was a man from Dundee
Who was fucking an ape in a tree.
The results were most horrid:
All ass and no forehead,
Three balls and a purple goatee!
(Apparently, the penchant for dirty jokes is a family heirloom- see more)

* While studying at Indiana University, he was a member of the Delta Tau Delta fraternity chapter there. He may have even been president of the chapter at one point in his college career.


* To this day, doctors and nurses in Cincinnati still remember and revere him as a highly respected and skilled thoracic surgeon, who put in the first pacemaker of the city.


* Graeter's Ice Cream- chocolate with butterscotch topping, if one must put a point on it- is one of life's enduring pleasures, no matter what age or level of awareness, one can always enjoy it.


* Even twenty years after her death, and probably more than thirty since they divorced, my grandfather still, in his way, loves and respects my grandmother.


* It is a horrible thing to lose touch with reality away from your home and loved ones, with the dread and sense that when you die, it will be someplace that smells of talc, piss, disinfectant, and cafeteria food. No amount of stars awarded for best care facility can block out such fears.

* No matter how much we fucked up, fucked over, or are fucked up by our family, there is nothing else that compares to their presences at the end of our days. They are, in spite of all, the best comfort and most potent solace for our souls when our lives have burned down and gutter into the last days of light.

"Health nuts are going to feel stupid someday, lying in hospitals dying of nothing."- Redd Foxx

Literary Geekery

NOTE- This has been moved from my old blog, in an effort to consolidate the hammer space that is the internets. Therefore bear in mind that it was written back in the first week of August. Thanks.
I've been meaning to do this for a while, and since my insomnia is still on hyperdrive from a combination of Karen and Stew's wedding (amazing, beautiful), talking with Brendan into late into the night (don't even know where to begin, that may be a whole journal for all i know -_~) and stress from paper/work/LSAT/depression/whatever the hell... regardless, it's 4am and i'm still awake for the fourth time this week.

So. On that cheery note, my irrepressable English Major is rearing its cultured, geeky, and sadly neglected head (don't you just hate when the head is neglected?)... *ahem* Anyway. Ramblings indeed. Away we go into Facebook-meme literary goodness!

These were inspired by my good, but too often neglected friend Kate GC [another point for D.C.] whose facebook writings are always a nudge in the much longed-for direction of helping keep me in mind of all the good things there are to read!

15 Books I want [need] to read:

1) The Rise of Theodor Roosevelt (need to finish it)
2) Moby Dick -Melville
3) Slaughter House Five -Vonnegut
4) Vanity Fair -Thackery
6) Divisadero -Ondaatje
7) Neverwhere -Gaiman
8) The Handmaid's Tale -Atwood
9) Kushiel's Mercy -Carey
10) Grief Counseling and Grief Therapy -Worden
11) The Guide to Getting It On, 6th Ed. (need to read revised edition)
12) East of Eden -Steinbeck
13) The Stranger -Camus
14) A Light in August -Faulkner
15) The Divine Comedy -Dante (again, need to finish it)

15 Literary characters I cannot help but love:

1) Almanzo, Farmer Boy -Wilder
2) Phedre, The Kushiel cycle -Carey
3) Viola, 12th Night -Shakespeare
4) Iago, Othello -Shakespeare
5) Mercutio, Romeo and Juliet -Shakespeare
6) Jane, Jane Eyre -Bronte, C.
7) Cal/Callie, Middlesex -Eugenidies
8) Gawain, Aurtherian tales/ Sir Gawain and the Green Knight
9) The Wife of Bathe, The Canturbury Tales -Chaucer
10) Jubal Harshaw, Stranger in a Strange Land -Heinlein
11) Maria, 11 Minutes -Coelho
12) Anita Blake, Bloody Bones -Hamilton
13) The Monster, Frankenstein -Shelley
14) O-Lan, The Good Earth -Buck
15) Peter -Matthew, Mark, Luke, John

And finally (likely not last, but at least for now), more proof of my literary geekery.

1) What author do you own the most books by?
Counting bound editions (though granted they're not, strictly speaking, books): Shakespeare; strictly speaking books: maybe Margaret Atwood, maybe Laurel K. Hamilton :p.

2) What book do you own the most copies of?
Lord of the Rings and Paradise Lost.

3) Did it bother you that both those questions ended with prepositions?
Yes, actually, it does.

4) What fictional character are you secretly in love with?
Well it wouldn't be much of a secret if I wrote it here, now would it? For [the blog's] sake, however, we'll go with Phedra, from the Kushiel series by Jacqueline Carey.

5) What book have you read the most times in your life (excluding picture books read to children; i.e., Goodnight Moon)?
Probably 12th Night, Jane Eyre, or The Odyssey.

6) What was your favorite book when you were ten years old?
Anne of Green Gables.

7) What is the worst book you've read in the past year?
*grimace* Night Falls Fast: Understanding Suicide, by Kay Jamison. It's not actually a "bad" book whatsoever, just incredibly difficult to read for emotional reasons.
[For more information as two why I have such a hard time with this book, see the PaperRave essay I wrote on it.]

8) What is the best book you've read in the past year?
Middlesex.

9) If you could force everyone you tagged to read one book, what would it be?
Twilight! *muahahaha*.... Um, no. Actually, Paradise Lost, if they haven't already.

10) Who deserves to win the next Nobel Prize for Literature?
I have no idea, as most of my favorite novelists are already dead...perhaps Rebecca Wells, author of Little Altars Everywhere and Divine Secrets of the Yaya Sisterhood.

11) What book would you most like to see made into a movie?
Maybe Kushiel's Dart, though it would likely get sadly watered down and mutilated.

12) What book would you least like to see made into a movie?
The Book of Genesis- what a terrible idea (I can just picture the CG effects now >_<).

13) Describe your weirdest dream involving a writer, book, or literary character.
Well, I once had this dream that Harry Potter got naked then went nuts with a bunch of horses... oh wait, that was Equus. [rimshot].

14) What is the most lowbrow book you've read as an adult?
Low brow...hm, probably some trashy romance novel, preferably one including vampires or the 17th century ^_^.

15) What is the most difficult book you've ever read?
Just books, Night Falls Fast; in terms of literature, The Sound and The Fury, by William Faulkner, or maybe Night, by Elie Wiesel.

16) What is the most obscure Shakespeare play you've seen?
Toss up between Henry VI, part II, and A Winter's Tale.

17) Do you prefer the French or the Russians?
I honestly haven't read enough of either to say definitively, but perhaps the French. [That being said, if you're interested in a non-headliner title for Russian novels, I recommend Ivan Turgenev's Father's and Son's. Hah- literature pretension re-established.]

18) Roth or Updike?
Haven't done either.

19) David Sedaris or Dave Eggers?
Again, haven't read either- not quite my style of author, I suspect, although I could be persuaded to try.

20) Shakespeare, Milton, or Chaucer?
Oooh. Tough call- Shakespeare for height of verse, Milton for depth of verse, Chaucer for humanity of verse.

21) Austen or Eliot?
I suppose Austen, though I honestly prefer the Brontes over either.

22) What is the biggest or most embarrassing gap in your reading?
Maybe modern literature (1940s to 1980s), although I'm surprisingly unversed in late 18th/19th century women writers.

23) What is your favorite novel?
Paradise Lost, Kushiel's Dart, 11 Minutes, Stranger in a Strange Land.

24) Play?
Long Day's Journey into Night, 12th Night, The Crucible, The Laramie Project.

25) Poem?
Sonnet 29 by Shakespeare, Every Day You Play by Neruda, To Autumn by Keats.

26) Essay?
How Not to Succeed in Law School, by James D. Gordon III, A Modest Proposal, by Jonathan Swift.

27) Short story?
Barn Burning, by William Faulkner.

28) Work of nonfiction?
SM 101, a Realistic Introduction, by Jay Wiseman.

29) Who is your favorite writer?
Likely Shakespeare, if I have to pick just one. Novelist- maybe Louise Erdich?

30) Who is the most overrated writer alive today?
Dan Brown? Nora Roberts? You decide!

31) What is your desert island book?
Norton Shakespeare Anthology or the Oxford Annotated New Revised Standard version of the Bible.

32) And... what are you reading right now?
Finishing The Rise of Theodore Roosevelt (eventually.. i swear i will!) and Eros, the Bittersweet.

Memoir Reflections: Night Falls Fast, Understanding Suicide, by Kay Redfield Jamison

Anna H.

For Scott Wiessman, 6/27/09

Mental Health Practice

In the book Night Falls Fast are Kay Redfield Jamison’s personal attempts, shared with the world, to understand the nature of, reasonings behind, and struggles leading up to a person’s choice to end his or her own life, and the subsequent devastation, horror, and confusion experienced those left to behind. In exploring her own ruminations, fear, and sadness about the prevalence of suicide—Jamison herself has bipolar disorder, and has been suicidal several times throughout her life, nearly completing once— and our western society’s intense discomfort with it as a world-wide mental health crisis, Night Falls Fast is aimed at filling in our lack of understanding about and empathy for those who suffer from and sometimes succumb to the lead contributors to suicidal acts: depression, manic-depressive [bipolar] disorder, schizophrenia, and substance abuse. In reading the book, however, it was my experience that Jamison seemed to get lost in gory details and terrible stories of bright lives consumed, focusing instead on the same sensationalism and voyeurism which she condemns in the general public treatment of this terrible phenomenon. Jamison, in setting out to dispel the stigma of suicide, insomuch as she can persuade her readers to recognize the struggles with mental illness most often behind it, falls frequently into the same culturally-bound showcasing treatment of suicide-as-spectacle that she criticizes. In this paper, therefore, I will examine the ways in which Jamison— despite her goals of addressing the dearth of knowledge about why and how people come to a decision of suicide and its underlying causes in such a way as to remove its stigma, that it may be more swiftly and easily addressed for public health— nonetheless struggles in her writing to escape the ways in which suicide is often treated in America: as morbidly fascinating, but largely incomprehensible.

Jamison’s book is not strictly a memoir in that, while she does include small personal narratives as a woman with an intimate history of suicidal ideation and attempt, she largely treats it as a collection of discourses, studies, and essays, all trying to make sense of how and why so many have and continue to take their own lives, and what do we who are left, or who survived, do to try to curtail its prevalence. Her own experiences with major bouts of depression, as the result of having bipolar disorder, seem to have a major impact in the way in which she writes the book, both in the loving and admiring prose with which she describes the multiplicity of brilliant and inspiring historical figures, known and unknown to the general reader, who eventually took their own lives, and in the brutally vivid details she embeds in our minds of their decent into a personal hell only escapable through suicide. I have no doubt that she identifies with her subjects, and in doing so takes her readers on the same terrible journey that she and they felt for the first two thirds of the book.

This book actually came highly recommended for me prior to taking 698 Practice in Mental Health by a friend who himself has struggled for years with bipolar disorder, as a window into the downward spiral of hopelessness one experiences in feeling suicidal, written by someone who had “been there” herself. I had sought out and spoken with Jim about depression and suicidal thoughts, in response to my own most recent experience of both— the third such in my lifetime— looking for someone who would understand how dark my vision had become, and in the course of dinner he brought up identifying with Jamison’s depictions and writings. I purchased the book, but could not bring myself to read it until it became absolutely necessary to choose a mental health memoir for class and I found Night Falls Fast already in my possession; ultimately, given my personal mental states over the course of 2009, I wish I had chosen a different book to use for this assignment, but I did finish it, albeit with reluctance, after much discomfort and some with secondary trauma. Unlike Jim, I would never recommend this book to a person currently battling the personal demons of depression, hopelessness, or suicidal thoughts: rather than feeling like I could empathize and relate from a healthy distance, Jamison’s style of storytelling is so terribly detailed, and her depictions so graphic, that I found myself frequently only able to read a handful of pages at a time before becoming profoundly disturbed. There is no wall that one can construct to protect themselves from these stories of real-life, unbearable suffering and often violent, grisly endings sought when they have felt the pain described in the pages before them. I struggled mightily with this book, and ultimately finished it, but was unsatisfied by the treatment it gave to both its subject, and its prognosis for the future.

Jamison, perhaps in exorcizing her own feelings at coming so close to becoming another casualty of her book, repeats over and over stories of young lives lost and great minds destroying themselves, multiplicities of statistics which numb the heart at their prevalence and methods of terrible sought-after release which felt physically harmful to read over and over again. Given the pain I felt in reading the repetition of stories with wrenching, early endings, the amount of loss experienced and the enumeration about ways people have sought their own demise, I can only hope their purpose serves to drive home the point of suicide’s terrible reality, and the need to intervene in seemingly senseless self-destruction. I fear, however, that it may serve the opposite end of further cutting off communications, either through desensitization, making these tales like a macabre depiction from a crime novel, or overwhelming the reader to the point where they do not know how they might deal with such pain in their own lives, and therefore shut down the possibility of open communication. I can imagine how powerful these depictions would be for someone who had not had firsthand knowledge of these feelings, that now they might really begin to recognize the crushing weight of these feelings, and how such an otherwise awful end might seem like relief, but for anyone recovering or still battling with depression themselves, reliving it within these pages is traumatizing and can threaten to suck you back in. In the book’s first two thirds’ unrelenting reiteration of violence and despairing, Jamison seems to be searching for answers to why people must suffer so, on behalf of those left behind, those who have survived their own attempts, and those who still consider suicide to be an option worth considering; there does not, sadly, seem to be a good enough answer to justify the inclusion of so much pain which assaults the reader. However, repeating again and again the same pattern of promising lives full of accomplishments already, devoured by mental health problems incomprehensible to those who have not felt their oppression, and ended for lack of hope that life will ever get better, Jamison’s ruminations, though disturbing as intrusive thoughts or flashbacks, do serve a significant purpose: suicide is de-romanticized in the extreme and laid bare and raw for the horror that it is, that the concerned reader might address it in his or her life and community with urgency and a somewhat better understanding.

I struggle with Jamison’s conflicting viewpoints, as she writes this book both as one who has fought continuously against depression in her own life—and thus far, won—and an upper class psychiatrist who uses the terminology of mental illness to describe not only schizophrenia and manic-depression, but also substance abuse and major depression. Hers is not a strengths-based model of study, and perhaps due to that, she focuses greatly on the pathology of suicide, particularly as it relates to genetics and is compounded by drug and alcohol abuse, leading up to the terrible details that go into the deaths of so many of her discussed examples. In effect, due to her major focus being the horrors of depression as it leads up to suicide, Jamison seems to largely ignore the positives of biopsychosocial input, tempered with protective factors, personal strengths, and multiplicity of treatment options— now more than ever used together to help prevent depression from growing so unmanageable— and she approaches the majority of her book with little hope and less optimism. Coping with bipolar disorder, Jamison gives her whole-hearted support to lithium, the classic mood-stabilizing drug; I have concerns, however, with her terming it the “antisuicide medication”, as it is a dangerous tendency, among Americans in particular, to assume or expect that one can oversimplify treatment of something with as complex a set of contributing factors as suicide. Despite her warning to readers that it may not work for everyone, terming anything with a cure-all designation is dangerous in a book so desperately lacking in hope for its readers, and I fear too many would latch on to one such buoy as their only possible salvation from suicidal ideation and eventual completion. My greatest criticism of Night Falls Fast, however, is that despite her seeming understanding of the dangers inherent in a culture-bound search for a magic bullet to “cure” these mental health issues and the expectations for a true “antisuicide medication”, as she discusses in the “As a Society” chapter on the how the media ought not to treat suicide, Jamison herself persists in using language and storytelling techniques which undermine her otherwise sound understanding of how to address suicide. Jamison quotes the CDC’s recommended guidelines to the media regarding suicide treatment as a paradigm for how suicide ought not to be portrayed: by presenting simplistic explanations for suicide, engaging in repetitive, ongoing or excessive reporting of suicide in the news, providing sensational coverage of suicide, reporting “how-to” descriptions of suicide [acts], presenting suicide as a tool for accomplishing certain ends, glorifying suicide or persons who commit suicide, or focusing on the suicide completer’s positive characteristics, (Jamison, 280-282). While she does not ignore all of these guidelines, despite including them in her book, Jamison herself still falls into these same habits during the first two thirds of Night Falls Fast, recounting multiple times the specific details of horrible deaths with morbid fascination, including as examples wonderful and famous minds in literature and art, and getting caught by her own condemnation.

What Jamison does do well is give factual evidence of the terrible impact that depression and its too-often-successor suicide do to individuals, regardless of gender or ethnicity, and their survivors. Using comprehensive statistical information and examples from all eras, nationalities, races and gender groups, Jamison poignantly illustrates that depression and suicide are great equalizers: they spare no population. That she is a well-educated white woman does show through in her more elaborate case examples and stories, in that most are about white men and women of prominence or potential (though with a few notable exceptions). Jamison does try to point out explicitly the troublingly ignored populations of homeless mentally ill, many of whom suffer from bipolar disorder or schizophrenia and for whom suicide is perhaps a more common option that with the general public, but recognizing that the greatest impact will be made on her audience with examples from more prominent—and therefore, theoretically better off— spheres of life, she spends the majority of her ink tracing more well known or well off figures from history who have succumb to suicide. Despite her best efforts to show the devastatingly vast scope of life suicide touches, non-white, non-educated populations remain largely unrepresented in this book, reflecting our cultural concern which only becomes actively alarmed when those who somehow should not be so desperate are taking their own lives.

The last third of the book is far less overwhelming, as it offers some light at the end of the tunnel in the form of treatment discussions and the usefulness of medication and public health awareness work, both of which are promising steps. It includes a discussion of most effective treatment methods—“Modest Magical Qualities”, with a discussion of both medicinal and therapeutic interventions—a discourse on the positive efforts public health workers have been making towards suicide awareness and prevention, and a sober conclusion discussing the impact of suicide on surviving family, spouses, and friends. Given the book’s publication in 1999, I think it would behoove Jamison to update for her audience, to add in the hopeful advancements of psychopharmacology in the past 10 years beyond what she discusses regarding the older generations of mood stabilizer, MAOIs, and tri-cyclic antidepressants, including the now common usage of most SSRIs and the new class of antidepressant medication, SNRIs. Similarly, while Jamison creates a depiction at once poignant and resilient of the family and friends left to rebuild themselves after the suicide of a loved one, she gives very little of herself, either as a survivor who managed to cope with the suicide of her dear friend (though we know not how), or how her own family coped with the darkness she lived in on and off throughout her life. Neither does she offer anywhere near as detailed accounts from the lives of others as she does for the deaths of those whose stories she does tell: this imbalance of perspective deprives us from taking away anything therapeutic, and keeps us perpetually sapped of emotional vitality all the way through to the book’s end.

As a student of social work, I was very pleased to read Jamison’s endorsement of combining psychopharmacology with therapy (psychiatry, in her case) as both her personal salvation and the best means of combating suicidal action. I truly wish that she had spent more time using herself as an example of those who can and do recover; despite having personally lost a number of friends and acquaintances to suicide, in addition to almost succeeding in taking her own life, Jamison is an emblem of hope for those who fear they cannot make it, yet she does not use her status as a model for others. We do not get to hear what worked for her, beyond sticking with her lithium and psychiatry regimen, we do not get to experience her headway made out of the depths of despair and into normal, even stellar functioning. Other than her dedication to her husband and brother, we know nothing about her support systems, which are not at all addressed elsewhere in the book’s tally of losses either. It is a significant failing on Jamison’s part that she leaves us without her own example of recovery from depression, or at least a discussion of its remission, as hope, to counteract the overwhelming burden left by the other stories in this book. We are left feeling unmoored and helpless after an onslaught of depressive stories, and instead of stressing those people and actions which did reach her through the darkness, we are left with only the smallest glimmers and told merely to keep holding on.

---

Jamison, Kay Redfield. (1999). Night Falls Fast, Understanding Suicide, Vintage Books: New York

Getting Through Grief with Yourself: Relearning Self-pleasure After the Loss of a Partner

Anna H.
For Sallie Foley, 5/3/09
SSW 700- Treatment of Sexual Dysfunction


Despite the copious amounts written in books and journals addressing the theories of, and approaches to, understanding and treating depression, grief and loss, and sexual (dys)functioning as isolated topics, very little can easily be found that looks at the intersection between these very common aspect of life. The loss of a romantic partner-- be it due to a breakup, separation and divorce, or death-- is a near-universally experienced part of human relationships. Stroebe, Schut & Stroebe report that particularly among older populations, as many as 45% of women and 15 % of men older than 65 become widowed (Stroebe, Schut & Stroebe 2007). Sadly, losses of this nature, though relatively common, are most often accompanied by a significant period of grief or bereavement, encompassing a multitude of emotions ranging from severe loneliness, to anger, relief, confusion or depression. Included among these are the very real, but not often acknowledged, needs for physical comfort and expression of one’s sexuality; despite this reality, however, modern healthcare and culture does little to acknowledge that sexuality remains a part of those people struggling with depression due to grief and loss, particularly if they are widows, widowers, or the elderly. Although self-pleasuring may or may not have been part of a client’s sexual routine before or during their time with their partner, learning-- or relearning-- ways to derive feelings of pleasure in both sensual and sexual experiences, safely, in the privacy of one’s own home, with the help of a sex therapist, can empower grieving clients to provide themselves with another means of solace.

In this paper I will discuss the ways in which therapists can help bereaved clients begin to reintegrate sexuality into their lives on their own, after the loss of a their partner, by affirming their need for comfort and pleasure and teaching them sensuality-focused means of self-pleasuring, even in the midst of grief. I will begin first with an overview of what Worden calls the “mourning process”, looking at how people proceed through what occurs after loss (Worden, 2009). I will continue on from there to discuss the integration of sexuality into grief, bearing in mind that the assumption of this paper is that clients are not dealing with a low sexual desire disorder per say, only sexual desire mitigated by grief. Due to the dearth of study on specific treatment for learning to use self-pleasuring as an outlet for sexuality and a source of comfort during the mourning process, I will finish with a discussion of sex therapy approaches used in treating low sexual desire, low arousal, and overcoming orgasm difficulty. Through these, I hope to suggest a course of sex therapy tasks meant, in conjunction with continued therapy for bereavement and support, to make one comfortable with masturbation and more attuned to their body’s sexual response.

This paper focuses specifically on self-pleasure and masturbation practices as a safe and non-threatening sexual activity that can continue to be enjoyed even after becoming single, though there are many others which can be explored to whatever extent the client has interest. All that must be emphasized with a cautionary note is that a client’s emotional and physical safety stay of paramount importance in whatever sexual expression is chosen. Clients dealing with grief and loss are likely suffering through some degree of depression, and clinicians must be particularly aware of their clients’ moods, affect, and engagement in high risk behavior as a result.

Sexuality is not often talked about as an aspect of bereavement that deserves to be addressed and promoted as an aspect of life which does not simply end after the loss of a partner or spouse. Sex therapists have for years promoted the idea that adult sexuality continues for as long as we live, and even major life changes such as losing a partner do not have to spell the end of one’s sexual life or the enjoyment of sensual activities. “Divorce may impact your sexuality by depriving you of a partner… and widowhood… has a unique impact on your opportunities, desire for, and capacity to be sexual, but neither need derail your sexuality or sexual identity,” (Foley, Kope, & Sugrue, 34, 2002). In the context of grief and mourning, however, in order to get the stage of a therapeutic relationship where clients are ready and want to address their sexual needs, it is important that clinicians in all fields of therapy first understand better what the experience of loss does to a person, physically, emotionally, and psychologically.

Stroebe, Schut & Stroebe outline in their review of health outcomes related to bereavement that there are extensive implications for physical as well as mental health when one has lost a loved one, including strong support for the idea that the “quality or nature of the lost relationship has much effect on outcome [for the survivor’s experience of loss]” (Stroebe, Schut & Stroebe, 1967, 2007). Therefore, the impact on surviving spouses of deceased partners, or individuals who have just been through divorce, separation, or breakup, is that one can expect to go through much during his or her time of grief over both the loss of relationship and partner. Physically, loss frequently manifests itself in a variety of behavioral and psycho-somatic changes which make up, in part, the experience of grief. These can include changes in a number of activities and aspects of daily living which are also hallmarks of depression, such as fatigue, agitation, weeping, social withdrawal, loss of appetite, sleep disturbances, and physical complaints (Stroebe, Schut & Stroebe, 2007). Further, depression as a normal result of grief can directly negatively affect how one responds to things that once gave them pleasure, sensually and sexually. Changes in general mood, attitudes towards sexuality, and physical wellbeing can be as mild as losing interest temporarily in one’s favorite past times, or can be as severe as to cause anhedonia, or the inability to take pleasure, physically or mentally, from normally pleasing events and activities. Seidman and Roose describe reduction in sexual interest as one of the most common changes in sexual response during depression, which can express itself physically as well as emotionally; for example, roughly “one third of depressed men develop loss of nocturnal penile tumescence (NPT), suggesting that depression can impair the neurophysiology of arousal or genital vasocongestion,” (Seidman and Roose, 2001). For the purposes of therapy, what this translates to is that clinicians can reassure their clients confidently with normalizing statements that, if they experience symptoms of marked decrease in arousal or sexual interest, these are common grief reactions influenced by both the loss itself, that they will likely dissipate or lessen over time, and if the client wishes to work on them clinically, they are completely welcome to do so, as sexuality is a normal and healthy part of life, even during major loss.

Emotionally and psychologically, Worden explains that there are “tasks” involved with processing and moving through the “phases” of mourning which, though a client may not follow a linear progression of milestones, are nonetheless essential to understand if clinicians want to provide support and help through loss (Worden, 2009). The first of these is “to accept the reality of the loss…that the person is gone and will not return” (Worden, 2009). This becomes a more complicated matter if the client’s partner is not deceased, but rather they are divorces, separated, or otherwise no longer in a relationship. As the literature I found devoted to the process of grieving spends little time addressing losses of these natures, I will for the purposes of this paper apply the tasks of grieving a dead partner also to the tasks of grieving a now-ended relationship. Regardless of the type of loss, many newly-single or widowed people go through a period of denial, during which they struggle against the concept that their relationship has ended and will not be the same again; it may take a person a very long time to come to terms with this. The second task, according to Worden, is to “process both the emotional and behavioral pain of grief,” (Worden 2009). While the degree of pain over a loss may vary from person to person, and certainly is can be effected by the circumstances of the relationship’s end, all people feel some level of sadness and pain when a deep and once-profound romantic bond has been broken. The third task Worden describes is for clients to begin to adjust to the world without their loved one by their sides; this includes making “external adjustments” in their new roles as single people, and possibly single parents, while continuing to live their lives, and “internal adjustments” to how they now must think of themselves (Worden 2009). Finally, the fourth task Worden discusses is that the bereaved person must find an enduring connection with their former partner “in the midst of embarking on a new life”. At the core of this task is integrating the ended relationship into their lives, as something which shaped and was of great value to them, perhaps for many years, while at the same time acknowledging and beginning to move towards a new phase of life where that relationship is no longer a dominant feature.

A note on differences among grief experiences with regards to stigma in society and gender. Greenblatt noted in 1978 that the experience of widowhood is far more common, and implies that such loss is potentially more difficult to bear, for women than for men:
Spousal mourning is a problem that mainly affects women because they have greater longevity, are usually younger than their husbands, and their marriage rate after bereavement is lower than that of widowers. Loss of spouse is, of course, a tragedy of major proportions. A widow is not only faced with loneliness, loss of companionship, and unmet sex needs, but also lacks the comfort, information, and support of a partner of many years. If her income is reduced, which is often the case, the widow may find herself poorer…. The widow’s place in society may become complicated; many widows, as well as their friends and relatives, view widowhood as something of a stigma.
(Greenblatt, 1978)
While it is easy to dismiss these observations as antiquated and outdated because of their age, there remains a significant amount of truth to them, although I would argue that the stigma and hardships described above apply equally to both men and women. A person accustomed to living with their partner and sharing a household does need to suddenly cope with the practical loss of supportive income, as well as the emotional support and companionship of their former mate, as Worden notes in his third task of making the internal and external adjustments necessary to continue living with this new and major life change. Further, it does seem to be the case that those who go through grief at the loss of a partner, particularly those who are already marginalized such as the LGBTQ and aging populations, end up denied recognition as continuing to be sexual beings. Bent and Magilvy are some of the few who explicitly acknowledge that grief in lesbian women who have lost life partners is further complicated not only by their marginalized status in society generally, but in regards to significant legal disadvantages such as visitation rights for partners in hospitals, being allowed to be beneficiaries of wills, and in some cases custody battles for children (Bent and Magilvy, 2006). Feelings of intense hurt, anger, and confusion with regards to the legal issues surrounding partner loss for this population can make the mourning process all the more painful. Foley, Kope and Sugrue note that “unlike a woman’s young adulthood, later in life her single “sexual self” may not be highly valued by the culture. Women often remark that they have to encourage themselves to stay sexually vibrant,” (Foley, Kope and Sugrue, 2002). Very little research can be found which specifically studies the sexual health or wellbeing, or even the role that sex continues to play, in the lives of those who are mourning partner loss. As Greenblatt seems to be suggesting, the general population, despite the high likelihood that most of its members will experience just this type of loss at least once in their lives, seems unwilling to acknowledge that those with grief still wish to experience sexual pleasure. In part, gender differences may be considered to try an account for this bias when looking at the way men and women view sex and it role or function in their lives, despite our modern views about female sexual liberation, it continues to be at least more acceptable for a man to have sexual needs than a woman. Regardless of this gendered division, it is important to affirm clients in their sense of loss and loneliness in missing sex and sexual expression or intimacy with their former partner, and to encourage them in their wish to remain sexual even now that they are single.
With the understanding that clients can process these multiple tasks of mourning simultaneously as life and emotion dictate, I suggest that a counselor or sex therapist’s role begins to shift from just grief work to also exploring and reclaiming the client’s sense of sexuality in the context of loss is when the client has begun to take on Worden’s third task. Recognizing that those feeling emotional pain and grief over the loss of a partner may include clients who were seeing someone for 6 months or coupled to for 56 years, it is important for clinicians to let clients who come to them with grief process it and progress through their own phases of mourning without an expected timeline for “getting better”, or even getting to the point of wanting to incorporate their sexuality into their healing. Clients may not initially feel the desire to feel or act sexually, and a client’s sexuality may be dormant for quite some time; some clients may never want to be sexual with another partner again. Foley, Kope and Sugrue remind clients that there is hope, after one becomes single again, of remaining sexual, even without their former partner:
Some single women who were previously partnered can honestly predict that there is little likelihood that they will find a new sexual partner. Their sexual response to this status is as varied as their circumstances. Some choose not to be sexual at all, others continue to masturbate and explore sensuality, and some even choose to have occasional sexual experiences.
(Foley, Kope, Sugrue, 2002).
Though addressed to women, these considerations apply to all people reintegrating sex after partner loss, since, after a time, many people do find their sexuality reemerging, whether or not they feel they are done grieving. It is at this point that sex therapists may best add their input in regards to sexual expression and health, to reassure them that their sexuality, as an integral part of their humanity, is not at all inappropriate or wrong, and in fact can be a wonderful way to self-sooth and satisfy their desire for pleasure.

The tasks of working on low sexual desire hinge on a client wanting to feel sexual, or experience sexual pleasure- so too with expressions of sexuality after loss. If the client has reached a place in their mourning process where they wish to have the means to fulfill themselves sexually, then clinicians should be ready to provide them with ways that they may get reacquainted with their sensuality and sexuality, and back in the groove. Providing permission for a client to discuss their desire to have sexuality back in their lives and offering the therapeutic context as a safe place in which to redevelop a sense of sexual self after their partner is an ideal first step, as it reaffirms trust in the therapeutic relationship, and shows the clinician’s willingness to address all needs presented by their client as they cope with loss. As a warm up for therapists to begin work on sexual exploration, it is a good idea to ask the client for a background on their self-care regimen. Understanding what they are, or are not doing, to take care of and enjoy their bodies gives you a good jumping off point for addressing the physical need for human contact, and eventually sexual needs, and leads directly into the first exercises aimed at getting clients back in touch with their sexual and sensual selves. Ask if they ever go to a salon, or get massages, or if they have in the past, how comfortable they were with that experience. Such activities are a good way to provide for the need we all have for human contact, which may not otherwise be satisfied if the client does not have children or close friends nearby. Worden points out that “being able to discuss emerging sexual feelings, including the need to be touched and to be held, is important. The counselor can suggest ways to meet these needs that are commensurate with the client’s personality and value system,” (Worden, 2009). Engaging such activities, if they do not already, is also a non-sexual way of easing clients into a reawakening of their sensuality, and getting them to begin enjoying the sensations of their body again.

Sensate focus exercises are an excellent place to begin the therapeutic work of reintegrating sensuality and sexuality into a client’s life, regardless of whether they masturbated before or during their previous relationship, because they allow for a slow and non-threatening progression from imagination to action. Hertlien, Weeks, and Gambescia, emphasize the use of sensate focus exercises in the context of systemic sex therapy as part of treatment for several different sexual dysfunctions (Hertlien, Weeks, and Gambescia, 2009). In the context of reincorporating masturbation and self-pleasuring into the lives of bereaved clients seeking comfort and an outlet for their sexuality, sensate focus techniques can be a particularly useful tools to “practice skills they have learned in the office” for getting reacquainted with their bodies’ enjoyment after much emotional suffering and to
[e]xperience sensual and sexual touch within a familiar, relaxed, comfortable environment. The therapist prescribes detailed cognitive and sensual behavioral homework that incorporates sensual and eventually sexual touch. Each assignment involves small incremental steps that help to build confidence, competence, and an increased sense of efficacy in overcoming the sexual problem.
(Hertlien, Weeks, and Gambescia, 2009).

In the case of bereaved clients, the assignments taught also help to slowly restore their comfort and enjoyment of their sexuality without their partner’s involvement. Worden cautions that “there are those whose only sexual experiences have been with their deceased partner, so the counselor may need to address any anxiety concerning new sexual experiences,” (Worden, 2009). In reality, whether or not a client had had sexual experiences with someone other than their former partner, if they were in a long-term, committed relationship with that person and, for one reason or another, are no longer with them, then it makes sense that a client might feel nervous, uncomfortable, or perhaps even guilty at wanting to still be sexual without them. It is therefore an important task in therapy, in conjunction with the actual practice of sensate focus, to allow time for sadness or a renewed grief that the client now must practice their sexuality on their own, even if they are ready and want to begin moving forward.

Sensate focus is usually taught as a partnered activity, and it is therefore necessary to adapt the exercises to be done individually, and for at least some of the non-erotic focus exercises, such as receiving massage, to be done by a professional. Originally, the purpose of sensate focus was to systematically desensitize an anxious or disengaged partner to the anxieties and distractions which were preventing them from enjoying fulfilling sexual relations with their partner. However since “the blueprint of the exercise must carefully fit the situation”, clients can feel reassured that sensate focus can work for them as well, and that the plan they and their therapist come up with to gently and unhurriedly bring sexual experiences back into their lives will be only built to do what they want it to, and not push them too far or too fast (Hertlien, Weeks, and Gambescia, 2009). To achieve this, progression through the exercises must be made in very small steps, to avoid feelings of frustration or failure, be it to respond without grief or to respond at all.

Hertlien, Weeks, and Gambescia put forth nine functions of sensate focus which can be reconsidered and drawn on as they relate to grieving clients without partners. Of those that apply to clients wishing to resume their sexuality by themselves, the first is for the client to “become more aware of his or her own sensations”, meaning to pay attention, during the exercise, purely to the physical senses they experience when they, for example, run their hand over their arm, or rub lotion into their feet (Hertlien, Weeks, and Gambescia, 2009). This may be particularly difficult to do when starting out with a client who is in the process of mourning, as they have been working so hard already in managing their emotions, maintaining their daily lives, and trying to move on after their partner is no longer with them. The grieving process described above from Worden is a challenging and highly strenuous emotional and mental task, and to tell a client to focus on setting all that aside for a while may be met with relief, or anger, or utter bewilderment. Eventually, however, the hope is that in training their mind to let itself rest for these few minutes or hours, and just experience sensations that are pleasurable and comforting, the client will find the ability to both enjoy their sexuality for itself and use it as a healthy, temporary relief from all the other feelings they have. The second function which can be utilized by the single client is to “focus on one’s own needs for pleasure” (Hertlien, Weeks, and Gambescia, 2009). In this context, this translates to the client training him or herself to pay attention to what their body tells them it wants, and not feeling guilty or conflicted about satisfying those needs and wants without the help, participation, or support of their former partner.

The third and possibly most vital function that such clients can make use of in their own plan is to “expand the repertoire of intimate, sensual behaviors” that they currently have (Hertlien, Weeks, and Gambescia, 2009). This can mean anything that the client is comfortable and has interest in exploring: if they enjoy the feel of satin, perhaps they can see what it is like to sleep on satin sheets; if they never learned how to masturbate, now is the time to learn. It is important to use positive language when offering or hearing out options for clients to consider when expanding their sexual repertoire, and to encourage anything safe that might promote arousal and sexual feelings to get a client in a sexual frame of mind. Clients may wish to incorporate erotic novels, videos, or pictures into their practice, and this may be particularly useful if they wish to try and develop new sexual fantasies that do not involve their former partner. Alternatively, if for example remembering erotic moments with their deceased spouse is not too painful, and they can incorporate them in a healthy way which allows them to experience sexuality without their partner, but still keep the memory of them close at heart, clients should not be discouraged from using what feels good to them.

Foley, Kope, and Sugrue include masturbation in their chapter on overcoming low arousal as an exemplary means of finding out what one enjoys and one of the safest ways to experiment with sexuality on one’s own. “A number of writers have suggested that masturbation serves as the ideal learning opportunity for people to explore hour their bodies respond to stimulation,” (Foley, Kope, and Sugrue, 2002). Unfortunately, masturbation remains a largely taboo subject, which the client may take some coaxing to talk about, be it to admit to doing it, in which case they should be applauded for knowing and enjoying their bodies, or to admit they don’t know how, to which a therapist would do well to reply that their client is not alone, and if they want to try learning, there are a number of fun and non-threatening ways to go about it.

In a society where sexuality can focus more on giving pleasure to a partner than giving pleasure to yourself, masturbation has developed an unsavory reputation as being selfish, dirty, and practiced by those who aren’t getting any ‘real’ sex…. The fact is, masturbation is a great way to get in touch with your own sexual responses, rhythms, and desires, and can be part of anyone’s sex life, whether or not he or she has a partner. Masturbation is a natural, healthy part of sexuality and sexual practices worthy of recognition in its own right, whether or now you ever use a vibrator.
(Blank and Whitten, 2000.)

To help with masturbation practices in both men and women, many counselors recommend the use of sex toys, including vibrators, massagers, dildos, and anal plugs, both to increase stimulation for those people who have had trouble orgasming with manual stimulation, for those who simply want a change of pace, or for those miss the feeling of fullness being with a male partner can provide. Blank and Whidden have reassuring words for those of more conservative backgrounds who might be uncertain about introducing anything man-made into their sexual activities: “The only real difference between using the vibrator and using your hand(s) to masturbate [or a penis for penetrative sex] is that the vibrator moves faster and has more endurance. It won’t change the ways and places you like to be stimulated,” (Blank and Whidden, 2000). Clients should never feel ashamed or embarrassed if they are unsure or don’t know how to masturbate, with or without the help of a toy, and again it is the job of the therapist to reassure their client that their exploration of their sexuality on their own is healthy and positive.

Using these techniques, therapists and counselors can work with bereaved clients who have lost partners to replenish their sense of a sexual self and to reassure them of the importance of their continued sexuality, if and when they are ready to return to it. Recognition of their struggles and pain, acknowledgement of their loss, and support and constructive help in creating exercises to aide them in their return to life as a sexual being, as well as a bereaved person, are the first important steps that a therapist can offer in to met their client’s needs. Always keeping in mind the process of mourning in which clients are actively engages to one extent or another, and the need for clients to have time to grieve over the immense changes they have had to go through-- both in their everyday lives and in their expression of sexuality-- therapists can help facilitate clients’ learning of the use of self-pleasure as a means of self-soothing, an outlet for sexual feelings, and a tool to sustain them as healthy individuals for the rest of their lives.

 
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Foley, Sallie, Kope, Sally & Sugrue, Dennis. 2002. Sex Matters for Women: A Complete Guide to Taking Care of Your Sexual Self. NY: Guilford Press.
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